17,1 Johnson: Streptococcus Hemolyticus 95 
inserting the finger into the same, the apex of the heart was felt 
distinctly under the finger. Reflex light thrown into the aper- 
ture revealed the apex of the heart to full view. A similar 
opening existed in the interspace. The parietal layers of the 
pleura and pericardium were adherent to themselves and ad- 
herent to the chest wall. A sinus existed between the pericar- 
dial cavity and the outside of the chest wall. A large purulent 
pericardial effusion, rapidly formed, had ruptured through the 
intercostal muscles spontaneously and had caused necrosis of the 
costochondral junction of the fifth left rib, and by means of the 
incision made through the skin an opening now existed from the 
exterior to the interior of the pericardial cavity. The patient 
lived three days in this condition. He died on the twentieth day. 
Through some misunderstanding only a partial autopsy was 
performed, which demonstrated the pericardial sinus as de- 
scribed, and a condition of the joints in which the joint surfaces 
eroded until the bare bone ends lay in direct apposition. Pus 
was obtained from the peritoneal cavity and from the spinal 
canal. 
This case was followed by another, with the primary infection 
in the lungs, which was demonstrated to be streptococcus hemoly- 
ticus and went on to the same fatal termination, developing all 
the severe involvements with the exception of the pericardium 
and joints. 
This particular type of streptococcus played a large and im- 
portant part in the causation of post measles and influenza 
pneumonia, at the army cantonments during 1918. The infec- 
tion is usually a local process, but in some cases it may be a 
primary septicaemia. 
The pneumonitis caused by this organism, occurring either 
primarily, or secondary to some predisposing disease, is of a pe- 
culiar and characteristic type. It is particularly fatal and prone 
to complications, the most common of which is empyema. In 
general, it may be said that streptococcus hemolyticus pro- 
duces a bronchopneumonia affecting primarily the framework 
of the lungs and bronchial walls. The name interstitial pneu- 
monia has been suggested, and it describes the condition. It is 
more or less associated with a diffuse or patchy lobular pneu- 
monia. The bacteria can be found scattered in the alveolar 
exudate. Areas of this kind may, and frequently do, become 
confluent, and resemble a lobar pneumonia. 
As shown by Tongs, the tonsils, especially the hyperplastic 
ones, are a frequent breeding place for the hemolytic strepto- 
